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General NPI Number Information
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NPI Number | 1003466947
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Entity Type | Individual
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Provider Name | EVA-SOPHIA CLARK MA, LCSW, LCDC, EMDR
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Gender | Female
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Dates
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Enumeration Date | 09/12/2019
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Last Update Date | 03/21/2021
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Provider Practice Location Address
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Address Line | 501 S CARROLL BLVD STE 203
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City | DENTON
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State | TX
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Zip | 76201-7423
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Country | US
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Telephone | 682-299-9406
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Fax |
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Provider Business Mailing Address
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Address Line | 12650 N BEACH ST STE 114
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City | FORT WORTH
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State | TX
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Zip | 76244-4245
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Country | US
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Telephone | 682-299-9406
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 66542
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License Number State | TX
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